Having gender-affirming documents, such as a passport, driver’s license, or birth certificate, may improve mental health among transgender adults, according to findings published today in The Lancet Public Health from researchers at Drexel University’s Dornsife School of Public Health.

“Having IDs that don’t reflect how you see yourself, and how you present yourself to the world, can be upsetting,” said lead author Ayden Scheim, PhD, an assistant professor in the Dornsife School of Public Health. “It can also potentially expose people to harassment, violence, and denial of service. Despite this, the relationship between gender-concordant ID and mental health had not previously been examined in the US.”

The study used data from 22,286 adults in the United States who participated in the 2015 US Transgender Survey -- conducted by the National Center for Transgender Equality -- and were living day-to-day in a gender different from the one assigned at birth. Just under half – 45% – did not have their preferred name and gender designation on any identification documents, 44% had limited gender-affirming identification and just 10% had their preferred information on all documentation.

As compared to those with no gender-affirming identification, those with their preferred name and gender on all documents were 32% less likely to be classified as seriously psychological distressed, 22% less likely to have seriously considered suicide in the past year, and 25% less likely to have made a suicide plan in the last year.

The work is first study in the United States to look at the connection between identification documents and improvements in multiple measures of mental health, including suicidal thoughts. A previous study from Canada found that, among trans men and women living full-time in their gender, having updated documentation lowered suicide thoughts and attempts.

“The process, costs, and restrictions associated with updating identification documents vary from state to state,” said Scheim. “These roadblocks prevent many people from getting the documents they need.”

In addition to benefits in social interactions, such as ordering a drink in a bar, having ID is typically required to receive health care, obtain employment, open a bank account and other aspects of life. The process for changing identification documents can vary greatly.

California Rep. Ro Khana recently introduced a bill championed by transgender rights groups that would allow an unspecified or “X” option on a passport, in addition to the “M” or “F” genders currently listed. If the bill becomes law, this option would be available to any U.S. citizens identifying as nonbinary or intersex, even if their home state does not allow the X option on driver’s license or other state issued IDs.

Although previous studies have looked into how medical gender affirmation procedures, such as hormones and surgery, impact mental health, very little is known about how legal identification affects mental health.

“Having accurate identification should be a fundamental human right. While many of us take it for granted, obtaining IDs can be very difficult for trans people,” Scheim said. “This is an area where tangible and relatively simple policy changes could aid public health.”

The researchers note that psychological distress and suicidal thoughts might have made it more difficult for participants to obtain updated identification, rather than the lack of identification leading to the poor mental health. Despite this limitation, the study’s data comes from the largest sample of trans adults ever surveyed and controls for other factors that could contribute to the connection between identification and mental health.

In light of this finding, the authors advocate for reducing or removing the barriers to changing gender and name on forms of identification, or possibly even removing the mention of gender.

“Beyond reducing barriers to changing gender and name on ID, we should be asking why gender needs to be indicated on photo ID at all,” Scheim said. “Including this attribute serves no clear purpose for identifying people -- that’s what the photo is for.”